Hiatus hernia
Herniation of the stomach through the diaphragmatic hiatus (sliding or rolling/para-oesophageal)
Overview
Protrusion of the stomach through the oesophageal hiatus of the diaphragm. Sliding (commonest) — the gastro-oesophageal junction slides up, predisposing to reflux. Rolling/para-oesophageal — the fundus herniates beside the oesophagus with the junction in place, risking strangulation. Often asymptomatic; managed as GORD, with surgery for large/para-oesophageal or complicated hernias.
Recognise
- Often asymptomatic; reflux symptoms (heartburn, regurgitation), sometimes chest discomfort, dysphagia or early satiety
- Sliding: associated with GORD; Rolling: risk of incarceration/strangulation/volvulus (acute severe pain, can't pass NG)
- Found incidentally on CXR (retrocardiac air-fluid level), barium swallow, endoscopy or CT
Red flags
- Para-oesophageal hernia with acute severe pain/obstruction → strangulation/gastric volvulus — surgical emergency
- Progressive dysphagia/weight loss → endoscopy
Differentials & how to tell them apart
Investigations
Often incidental (CXR retrocardiac gas/fluid level); endoscopy or barium swallow; CT defines anatomy.
Management
Treat reflux (PPI + lifestyle); surgery for large/para-oesophageal/complicated
- 1Manage symptomatic sliding hernias as GORD (PPI + lifestyle).Gate: A para-oesophageal (rolling) hernia with acute severe pain/obstruction is a surgical EMERGENCY (strangulation/gastric volvulus) — not a reflux problem
- 2Surgical repair for large symptomatic or para-oesophageal hernias.
Key points
Sliding = reflux; rolling/para-oesophageal = strangulation risk (surgical). A retrocardiac air-fluid level on CXR is the classic incidental clue.
Monitor & prognosis
Symptoms; complications of large hernias.
Good; para-oesophageal hernias can strangulate.
Source: NICE; StatPearls